Reporting from Canada, #11: A Dialectical Approach to Resolving Recalcitrant Social Psychiatric Problems

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

In clinical psychiatry, it took an innovative clinical approach to improve the treatment outcomes of patients with borderline personality disorders and related conditions. It is a dialectical approach developed by Marsha Linehan and others.¹ It attempts to recognize trauma triggers, teach control of volatile and conflictual emotional reactions, how to cognitively resolve polarizing perspectives, and improve relationships. Early developmental uncertainty and confusion seems responsible, and corrective emotional experiences the potential antidotes.

Being in Canada recently, I was exposed to some different views on major social psychiatric problems, such as the Mideast War. Canada reports that it is about ready to recommend a Palestinian state. That differs from the United States. As this tentative theoretical idea about a dialectical approach emerged for me, Israel just announced a controversial new plan to occupy Gaza until a neutral government can be established. The first stage is apparently to end on the very significant second year anniversary of the war.

In forums of discussion among psychiatrists, I continue to see deep disagreement and narcissistic embrace about responsibility for the humanitarian crisis in Gaza. One side blames Israel and Zionism; another side blames Hamas and the martyrdom of Gazans, including and particularly children. These sides are complicated by the questionable reliability of some information. Connected to this conflict is rising anti-Semitism and Islamophobia, as well as increasing conspiracy and cultish reasoning. Perhaps the truth is somewhere in between the extremes.

There can also be conflict within particular groups. Among Jewish people, there is some divisive opinions over who is responsible for the nature of the ongoing war and the remaining Israeli hostages.

Personally, there can be conflict between person moral beliefs and professional ethical principles. That leaves uncertainty about what can be applied from the unique knowledge and skills of psychiatry.

To me, it is what psychiatry in particular can contribute that should be our unique priority. So far, we are a relatively quiet and passive participant in the public and professional debates, but silence will not eliminate the always present political influences on our field. Here is a 10-point program of how and what could happen with such a new emphasis.

• Always try to apply and prioritize psychiatric perspectives.
• Use the dialectical approach to resolve extreme and volatile emotional positions.
• Value diverse opinions.
• Do not give up and drop out.
• Approach social psychiatric conflicts like we do with individual patient conflicts, with empathy, compassion, compromise, learning, therapeutic intention, and possibly forgiveness.
• Watch for and try to prevent the ongoing risk of psychiatric repercussions such as delayed posttraumatic stress disorder, personal moral injuries, and prolonged grief disorders.
• Find and connect with other groups to fulfill general humanistic needs and personal moral beliefs.
• Avoid what could be called social countertransference—that is, the intentional and unintentional intrusion of politics into individual patient care.
• Be potentially flexible.
• Be culturally humble.

Effective leadership will be necessary, leaders with transformative and bridging skills, not authoritarian ones. It will also take courage and innovation to try to apply what is successful with individual patients to social groups. Social mistrust needs to be turned into verifiable trust.

This new hypothesis may be erroneous and not work. It might take recognition, acceptance, and ongoing monitoring of Israel’s right to exist; Palestinians would have to have an appropriate land to survive and thrive with new leadership. The past and status quo has proved to be a failure in resolving the long and destructive conflict that has developed for centuries among people from the same lands.

Other intragroup and international conflicts continue too: Ukraine and Russia, in Myramar, in Sudan, the displaced and discriminated-against Indigenous in many countries, and American political parties, too, among others. Instead of a “divide and conquer” strategy, we need a “unite and forgive” process.

Once upon a time, the treatment of patients with borderline personality disorder was full of pessimism. No more. Can we do the same with large scale group conflict? Or is this a Don Quixote fantasy?

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

Reference

1. Linehan M. Building a Life Worth Living: A Memoir. Random House; 2021.